How to write a Therapy Intake Report: A practical guide for clinicians

When we sit down to document a new client’s story, we’re not just filling out forms, we’re shaping the clinical frame that will support our work together. The intake report is often the first structured reflection of this process. It documents essential information, articulates treatment goals and clinical formulations, supports continuity of care, and establishes that treatment is clinically indicated.

Whether you’re working independently, in an agency, or within a multidisciplinary team, the intake report is a foundational piece of documentation. It serves not only as a professional record but also as a thoughtful summary of how the client presents at the outset of therapy. Throughout the course of treatment I find it can be very helpful to return to the original Intake Report periodically as a reminder of how the therapy process began.

In this short guide, I outline a clear, structured approach to writing an intake report that supports professional, ethical, and insurance-related standards, while also preserving the human qualities that brought us into this work.

What is a therapy Intake Report?

An intake report documents the information gathered during the initial assessment or intake period. It includes both descriptive and clinical material, helping to form the basis of a treatment plan. When written well, it reflects careful listening, thoughtful observation, and clinical judgment.

A complete intake report typically includes the following sections:

• Demographic and administrative information
• Presentation
• Psychosocial background
• Assessments
• Themes
• Clinical impressions
• Recommendations and treatment plan
• Informed consent and treatment contract

Each section contributes to a fuller understanding of the person seeking care.

1) Demographic and Administrative Information

This section includes basic identifying and logistical information:

• Name, date of birth, contact details
• Referral source
• Pronouns and/or gender identity (as reported)
• Insurance or billing information (if applicable)
• Therapist name and credentials
• Date and location of intake session (e.g., in-person, telehealth)
• Consent preferences (voicemail, email communication)

Much of this data is often gathered via a standardized intake form, but it’s important to review it directly with the client to ensure accuracy and relevance.

For this section we ask ourselves:

💡 What are the client’s key identifying details and what administrative information is required?
(e.g., name, date of birth, contact info, referral source, marital status, session format, CPT/diagnostic codes, emergency contact, fee arrangements)

2) Presentation

Here, we describe how the client appeared and engaged during the session. This includes both self-reported and observed elements:

• Physical presentation and demeanor
• Mood and affect (reported and observed)
• Speech, behavior, cognitive functioning
• Approach to the session (e.g., engagement, communication style)
• Presenting concerns, in the client’s own words where possible

The tone should be observational and neutral. For example:

“The client appeared anxious and withdrawn, spoke softly, and avoided sustained eye contact.”

This section is not the place for interpretation or speculation; rather, it invites us to begin describing the client with care and clarity.

For this, we ask ourselves:

💡 How did the client present during the intake session—emotionally, physically, and interpersonally? (What was their demeanor, affect, appearance, and manner of engagement? How did they approach the session?)

💡 What problems led the client to seek therapy, and how do they describe their current difficulties?
(What symptoms or struggles are they reporting? How long have they been experiencing them? What have they tried so far?)

💡 When did the client’s difficulties begin, and how have they developed over time?
(What contextual or precipitating factors are relevant? Are there past attempts at help-seeking or changes in severity?)

💡 What is the client’s current emotional and cognitive state, both reported and observed?
(How are they feeling and functioning mentally? Is there evidence of distress, dissociation, or strong insight?)

3) Background

The background section offers context for the client’s current difficulties. Depending on the clinical focus and setting, this may include:

• Family and developmental history
• Childhood, adolescent, and adult experiences
• Education and work history
• Relationships, sexuality, and social support
• Medical history and current health concerns
• History of therapy or psychiatric treatment
• Cultural, religious, or identity-related factors

Phrases such as “The client reported…” or “According to the client…” help maintain accuracy without assuming the role of narrator or fact-checker. When impressions are offered, they should be framed tentatively and supported by observed data.

This is also a space to attend respectfully to trauma disclosures, without requiring excessive detail unless clinically necessary.

Here we ask:

💡 What aspects of the client’s personal, developmental, and psychosocial history are relevant to understanding their current concerns?
(e.g., family history, education, work, relationships, trauma, sexuality, hobbies, cultural identity, strengths)

💡 Does the client have any relevant medical conditions or past treatments that may impact therapy?
(e.g., chronic illness, psychiatric diagnoses, medications, prior therapy, hospitalizations)

4) Assessments

If any structured assessments were administered during the intake, summarize their purpose and the general findings here:

• Symptom measures (e.g., PHQ-9, GAD-7)
• Functional assessments (e.g., WHODAS 2.0)
• Risk assessments (e.g., C-SSRS)
• Cognitive or personality instruments (if applicable)

Rather than listing raw scores, offer a clinical interpretation:

“Scores on the PHQ-9 suggest moderately severe depressive symptoms, consistent with the client’s reported difficulties functioning at work.”

Note the client’s response to the assessment process as well. Emotional reactions to structured tools can yield meaningful insight.

To write this section we ask ourselves:

💡 Have any assessments been conducted, and what were the relevant clinical findings?
(e.g., results from symptom measures, functional assessments, or diagnostic tools—summarized, not raw scores)

5) Themes

For clinicians who find it helpful, this section can distill the intake into core themes that may guide treatment:

• Anxiety and worry
• Relational or attachment concerns
• Identity and self-esteem
• Trauma and its effects
• Grief and loss
• Life transitions and adjustment
• Somatic complaints
• Work or academic stress

Not every report requires this level of thematic structure, but identifying key domains can help clarify the focus of future sessions.

The main question we are addressing here is:

💡 What major themes or categories emerged during the intake discussion?
(What patterns, stressors, or areas of concern came up repeatedly—e.g., trauma, loss, identity, relational issues?)

6) Clinical Impressions

This is where we begin to integrate the data gathered into a preliminary clinical picture. This section may include:

• Clinical observations
• Relevant biopsychosocial factors
• Diagnostic impressions (if used)
• The therapist’s working formulation

If a formal diagnosis is offered, use language that is precise yet respectful:

“The client meets DSM-5 criteria for Major Depressive Disorder, moderate, with anxious distress.”

If you do not provide a diagnosis, this is still the place to summarize the client’s core challenges as you currently understand them.

When including a clinical formulation, it’s important to acknowledge the tentative and evolving nature of this understanding:

“It appears that early relational trauma, combined with current work stress and limited social support, may be contributing to the client’s symptoms of anxiety and self-doubt.”

This is not about presenting a definitive theory of the client but rather beginning to frame the clinical work ahead.

Here we ask ourselves such things as:

💡 Based on the intake, what are my preliminary clinical impressions of the client?
(How do I understand the client’s presentation from a biopsychosocial perspective? What diagnostic impressions apply?)

💡 What is my working understanding of how the client’s difficulties developed and are being maintained?
(What psychological, relational, biological, or environmental factors contribute to the clinical picture?)

7) Recommendations and Treatment Plan

Here, we describe our recommendations based on the intake and formulation. This often includes:

• Recommended frequency and type of therapy
• Referrals (e.g., psychiatry, support services, group therapy)
• Initial goals and focus areas
• Proposed interventions or methods (e.g., CBT techniques, trauma-informed care, relational exploration)
• Target outcomes and timeframes (where appropriate)
• Medical Necessity

In contexts where insurance is involved, it’s helpful to connect your recommendations to medical necessity and document how the treatment addresses the client’s current level of impairment or distress.

Where applicable, SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound) may be useful—but not all therapeutic work fits neatly into this structure, and that’s okay.

For this section we ask:

💡 What treatment recommendations do I have, and what are the initial goals and time frame?
(What therapy approach is indicated? Are any referrals needed? What are the focus areas and goals of treatment?)

💡 How is the treatment a medical necessity for the client?
(What functional impairments or clinical needs support the necessity of treatment at this time?)

8) Informed Consent and Treatment Contract

The final section of the intake report documents that informed consent was obtained and that the terms of treatment were discussed. This may include:

• Nature of therapy and therapeutic boundaries
• Confidentiality and its limits
• Cancellation policies and fees
• Use of telehealth or electronic communication
• Emergency procedures
• Authorization to communicate with other providers (if applicable)

Indicate whether written or verbal consent was obtained and note that a copy of the signed consent form is retained (if applicable). In many U.S. jurisdictions, clear documentation of informed consent is a legal requirement and part of ethical best practices.

Include a signature block and date the report when finalized. Some jurisdictions also require that our notes and reports be “time-stamped” -so be sure to include that as well if needed.

For this final section we ask ourselves:

💡 What informed consent details were reviewed, and what expectations were agreed upon?
(e.g., confidentiality, risks and benefits, attendance, fees, crisis procedures—was written or verbal consent obtained?)

Final Reflections

The intake report is not just a formality, it’s a clinical act in itself. It invites us to think carefully about how we represent the client, how we formulate their needs, and how we propose to help. When written clearly and compassionately, the intake report supports ethical care, professional communication, and thoughtful treatment planning.

Just as importantly, it reflects our presence and the integrity of our work. It says: I am paying attention. I am listening. And I am committed to this work.

At Note Designer, we offer a thoughtfully designed Intake Report template built specifically for mental health professionals. The template includes clearly labeled sections, structured prompts, and a bank of professionally written content to support thorough, clinically sound documentation—while also helping to ensure that medical necessity is clearly stated. Whether your focus is trauma, mood disorders, identity, or relational work, the content can be tailored to reflect your clinical orientation and the needs of each client. Note Designer also includes an optional AI-Rewrite feature that can help refine the tone and structure of your report after drafting—gently improving clarity and flow while preserving your clinical voice.

Note Designer is built to meet real-world clinical and administrative needs because it’s created by fellow clinicians (we get it).

By Patricia C. Baldwin, Ph.D.

Clinical Psychologist

Co-Founder Note Designer Inc.

Author of

Note Designer: A simple step-by-step guide to writing your psychotherapy progress notes (2^nd Edition – updated and expanded); 2023.

👩🏻‍💻 This blog post is derived from Chapter 1 of Note Designer: A simple step-by-step guide to writing your psychotherapy progress notes (2^nd Edition- updated and expanded); 2023

© 2025 Patricia C. Baldwin. All rights reserved.
This blog post is the intellectual property of Patricia C. Baldwin and may not be reproduced, distributed, or transmitted in any form or by any means without the prior written permission of the author. Brief quotations may be used with appropriate citation and link to the original source.